Closed-loop therapy in older adults with type 1 diabetes: hypoglycaemia benefits and risk stratification – Authors' reply
Authors: Richard E Pratley, Anna Casu
Journal: The Lancet Healthy Longevity (2022)

We thank Sybil McAuley and Steven Trawley for bringing the recently published results of the ORACL trial1McAuley SA Trawley S Vogrin S et al.Closed-loop insulin delivery versus sensor-augmented pump therapy in older adults with type 1 diabetes (ORACL): a randomized, crossover trial.Diabetes Care. 2022; 45: 381-390Crossref PubMed Scopus (9) Google Scholar to our attention and apologise for not including their work in our recent Comment.2Pratley RE Casu A Can technology improve the management of older adults with type 1 diabetes? Yes, but….Lancet Healthy Longev. 2022; 3: e120-e121Summary Full Text Full Text PDF Scopus (2) Google Scholar In this study, they and their colleagues report that, relative to sensor-augmented pump therapy, a hybrid closed-loop insulin delivery strategy was associated with significant improvements in time in range measured by continuous glucose monitoring in older adults with type 1 diabetes. Moreover, and in contrast to the study of Charlotte Boughton and colleagues,3Boughton CK Hartnell S Thabit H et al.Hybrid closed-loop glucose control compared with sensor augmented pump therapy in older adults with type 1 diabetes: an open-label multicentre, multinational, randomised, crossover study.Lancet Healthy Longev. 2022; 3: e135-e142Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar they report small but significant decreases in hypoglycaemia with a hybrid closed-loop strategy. Both studies enrolled older individuals with long-standing type 1 diabetes who were, nevertheless, well controlled (mean HbA1c around 7·4%) and both used a crossover design comparing hybrid closed-loop insulin delivery with sensor-augmented pump therapy. However, participants in the ORACL trial were more diverse than in Boughton and colleagues' study; in the former, 30% had impaired awareness of hypoglycaemia and, importantly, more had evidence of mild cognitive impairment. The ORACL trial is, thus, an important addition to the growing evidence base supporting the use of technology to improve outcomes in older adults with type 1 diabetes and we completely agree with McAuley and Trawley who suggest that detailed characterisation of the clinical and functional diversity of older individuals enrolled in trials is warranted. Whether differences in participant characteristics or whether other factors, such as the algorithm itself, explain the disparate findings with respect to hypoglycaemia between the trials is difficult to ascertain. Of greater importance is the clear and consistent evidence from both studies that older individuals with long-standing type 1 diabetes can successfully use advanced insulin delivery technologies and realise the benefits seen in younger populations. We thank Sybil McAuley and Steven Trawley for bringing the recently published results of the ORACL trial1McAuley SA Trawley S Vogrin S et al.Closed-loop insulin delivery versus sensor-augmented pump therapy in older adults with type 1 diabetes (ORACL): a randomized, crossover trial.Diabetes Care. 2022; 45: 381-390Crossref PubMed Scopus (9) Google Scholar to our attention and apologise for not including their work in our recent Comment.2Pratley RE Casu A Can technology improve the management of older adults with type 1 diabetes? Yes, but….Lancet Healthy Longev. 2022; 3: e120-e121Summary Full Text Full Text PDF Scopus (2) Google Scholar In this study, they and their colleagues report that, relative to sensor-augmented pump therapy, a hybrid closed-loop insulin delivery strategy was associated with significant improvements in time in range measured by continuous glucose monitoring in older adults with type 1 diabetes. Moreover, and in contrast to the study of Charlotte Boughton and colleagues,3Boughton CK Hartnell S Thabit H et al.Hybrid closed-loop glucose control compared with sensor augmented pump therapy in older adults with type 1 diabetes: an open-label multicentre, multinational, randomised, crossover study.Lancet Healthy Longev. 2022; 3: e135-e142Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar they report small but significant decreases in hypoglycaemia with a hybrid closed-loop strategy. Both studies enrolled older individuals with long-standing type 1 diabetes who were, nevertheless, well controlled (mean HbA1c around 7·4%) and both used a crossover design comparing hybrid closed-loop insulin delivery with sensor-augmented pump therapy. However, participants in the ORACL trial were more diverse than in Boughton and colleagues' study; in the former, 30% had impaired awareness of hypoglycaemia and, importantly, more had evidence of mild cognitive impairment. The ORACL trial is, thus, an important addition to the growing evidence base supporting the use of technology to improve outcomes in older adults with type 1 diabetes and we completely agree with McAuley and Trawley who suggest that detailed characterisation of the clinical and functional diversity of older individuals enrolled in trials is warranted. Whether differences in participant characteristics or whether other factors, such as the algorithm itself, explain the disparate findings with respect to hypoglycaemia between the trials is difficult to ascertain. Of greater importance is the clear and consistent evidence from both studies that older individuals with long-standing type 1 diabetes can successfully use advanced insulin delivery technologies and realise the benefits seen in younger populations. REP declares grants to his institution from Hanmi Pharmaceutical, Janssen, Metavention, Novo Nordisk, Poxel, and Sanofi; consulting fees to his institution from AstraZeneca, Bayer, Corcept Therapeutics, Dexcom, Gasherbrum Bio, Glytec, Hanmi Pharmaceutical, Hengrui (USA), Janssen, Merck, Mundipharma, Novo Nordisk, Pfizer, Rivus Pharmaceuticals, Sanofi, Scohia Pharma, and Sun Pharmaceutical Industries; and travel expenses from AstraZeneca, Glytec, Merck, Mundipharma, Novo Nordis, and Pfizer. AC declares no competing interests. Can technology improve the management of older adults with type 1 diabetes? Yes, but…Technology-based approaches aimed at improving health have permeated our lives. Today, smart phone applications, smart watches, activity trackers, and an ever-evolving ecosystem of biometric trackers are in routine use by millions of consumers worldwide. Nowhere have advances in technology been more impactful than in the field of diabetes. For example, intermittent finger-stick blood glucose testing is rapidly giving way to newer technologies such as continuous glucose monitoring. Full-Text PDF Open AccessHybrid closed-loop glucose control compared with sensor augmented pump therapy in older adults with type 1 diabetes: an open-label multicentre, multinational, randomised, crossover studyHybrid closed-loop insulin delivery is safe and achieves superior glycaemic control to SAP therapy in older adults with long duration of type 1 diabetes. Importantly this was achieved without increasing the risk of hypoglycaemia in this population with risk factors for severe hypoglycaemia. This suggests that hybrid closed-loop therapy is a clinically important treatment option for older adults with type 1 diabetes. Full-Text PDF Open AccessClosed-loop therapy in older adults with type 1 diabetes: hypoglycaemia benefits and risk stratificationWe read with interest the Comment in The Lancet Healthy Longevity by Richard Pratley and Anna Casu questioning whether technology can improve the management of type 1 diabetes in older adults.1 Although the authors draw attention to important points, two key considerations warrant further reflection. Full-Text PDF Open Access